Health insurance reform almost here: What it means to you

Aug. 24, 2013

Nurse practitioner Sara Wallenius works with patient Kimberly Winters at the Western North Carolina Community Health Services clinic. The clinic will help people enroll in the new federal health insurance marketplace. / Bill Sanders / wsanders@citizen-times.com

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Determining who is eligible for help

• Many people will have a wide — and complex — range of options when the federal Health Insurance Marketplace opens Oct. 1. • For people who have affordable, employer-based coverage, nothing is likely to change. • People qualifying for health insurance subsidies must have an income 100-400 percent of the federal poverty level.

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ASHEVILLE — Melissa Bigg and her husband pay $348 a month for health insurance — but their deductible is $10,000.

Easily that puts the couple among the millions of people who will look for relief when a key part of President Barack Obama’s Patient Protection and Affordable Care Act launches Oct. 1.

People like Bigg, a 59-year-old owner of a small farm near Marshall, could see cost savings with the new Health Insurance Marketplace — or not.

Insurance companies and nonprofit organizations have been getting ready to help consumers navigate a daunting range of options.

More than 800,000 uninsured North Carolina residents will be financially eligible for federal subsidies offered by the Affordable Care Act, otherwise known as Obamacare.

Breaking down the Affordable Care Act

USA Today breaks down the Affordable Care Act and what it means to you in this slide show.

The insurance exchange or marketplace is intended to allow consumers to compare “apples to apples” when it comes to insurance. The law will also provide subsidies to help those at certain income levels pay for their health insurance.

“I’d be happy to pay what I pay now if I got better coverage and not this high deductible,” Bigg said.

“We’re just waiting for Oct. 1 when questions can really be answered,” she said.

For people who have affordable, employer-based coverage, nothing is likely to change.

But for those without insurance and without access to an affordable employer-based plan, the marketplace website will allow them to compare insurance plans.

And those with income between 100 percent and 400 percent of the federal poverty level can obtain government subsidies or tax credits that will cover part of the cost of their insurance plan.

Those who fail to purchase insurance will have to pay a penalty starting at $95 per adult, but there are exceptions.

Despite all the attention the law has received, many don’t realize the changes that are coming.

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A poll this spring by the Kaiser Family Foundation found that 42 percent of Americans didn’t realize the Affordable Care Act was still in effect. That poll found 12 percent thought it had been repealed by Congress.

Karen Pollitz, senior fellow at the Kaiser Family Foundation, said as the federal and state health insurance marketplaces prepare to open, “Hopefully, awareness will kind of turn around.”

“The main people to pay attention are people who don’t have health insurance now or who buy health insurance on their own,” Pollitz said.

Some basics

Of North Carolina’s more than 8 million people under the age of 65, 19.1 percent are uninsured, according to 2010 U.S. Census estimates.

Of the uninsured, more than 800,000 will be financially eligible for federal subsidies offered through the Affordable Care Act.

Not all of the more than 800,000 state residents financially eligible for federal subsidies will qualify.

Those getting subsidies must be a citizen or lawful permanent resident. People qualifying for public health care coverage (like Medicaid) or who have access to affordable, employer-based coverage will be ineligible.

In North Carolina, the Republican-led General Assembly opted not to expand Medicaid — another key part of the Affordable Care Act.

That means the state’s poorest residents — those below 100 percent of the federal poverty level — won’t qualify for assistance either in the form of subsidies or expanded Medicaid.

North Carolina also did not create its own exchange so residents here will go through the federal marketplace.

“The (federal exchange) website will tell you what you are eligible for and what it will cost you out of pocket,” Pollitz said.

The North Carolina Department of Insurance says three companies — Blue Cross and Blue Shield of North Carolina, Coventry Health Care of the Carolinas and FirstCarolinaCare have indicated their intent to take part in the individual market.

Each company has submitted multiple plans. It’s up to the federal government to approve which plans are included in the insurance marketplace.

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The state Department of Insurance has said that coverage options will vary by county.

The plans are divided into four categories — bronze, silver, gold and platinum. All the plans are supposed to provide some basic benefits.

But this is still private insurance so consumers will have options. For example, someone might decide to purchase a plan that has a higher premium but a lower deductible.

An important piece of the Affordable Care Act is the provision that says health insurers can no longer charge more or deny coverage because of a pre-existing condition.

Anyone can purchase insurance through the exchanges.

But not everyone will qualify for subsidies. And to get the subsidies you must purchase insurance through the exchange.

Penalties

The Affordable Care Act includes penalties for the uninsured who don’t purchase insurance.

In 2014, the penalty will be $95 per adult per year or 1 percent of income (whichever is greater), according to Pam Silberman with the N.C. Institute of Medicine. It will go up over time so by 2016, it will be $695 per year per person or 2.5 percent of income, whichever is higher.

That has some worried that some people will simply pay the penalty rather than purchase insurance.

And there are a number of exemptions from having to buy coverage.

Those include people who would have to spend more than 8 percent of their income for the lowest cost premium, people who pay no taxes because their income is too low, those with religious exemptions and members of federally recognized Indian tribes, Silberman said.

Other exemptions include those who would have been eligible for Medicaid in states that didn’t expand coverage like North Carolina. People who’ve had financial problems such as bankruptcy or homelessness can also gain an exemption.

“It’s important to note that many people will still need to apply for coverage through the Health Insurance Marketplace to get the exemption. Others will get their exemption from the IRS,” Silberman said in an email.

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Spreading the word

At federally qualified health clinics and at some community-based agencies in the state, workers and volunteers will educate and help residents enroll in insurance plans.

“We’re going to be assisting people with their applications,” said Scott Parker, with Western North Carolina Community Health Services.

Around 8,000 uninsured people use the WNCCHS clinic.

“Oct. 1, we will hit the ground running,” Parker said. “We’re gonna sort of phase it in here. We’re gonna start with any new patient who comes in.”

In addition to health centers like WNCCHS, some North Carolina organizations will have “navigators,” people who can assist those who need to enroll in an insurance plan.

“We will be setting up a system of volunteers and counselors who will sit down one-on-one with people and help them understand the benefit options available to them and help them enroll,” said John Wingerter, director of health insurance information services at the Council on Aging of Buncombe County. “The information we offer will be free, unbiased and it’s confidential.”

Another local agency that will be helping people enroll in an insurance plan is Pisgah Legal Services.

“The navigators are there so that there’s somebody’s whose job it is to help you who isn’t selling you anything,” Pollitz said.

Jim Barrett, executive director of Pisgah Legal Services, said his organization is still getting details on the navigators.

The nonprofit plans to recruit and train volunteers to help people fill out the necessary application.

“Folks who have not had insurance in several years, it’s going to be important to provide them support as they go through this process,” said Patsy Dowling, executive director, Mountain Projects, another Western North Carolina nonprofit that will have navigators available.

Blue Cross/Blue Shield of North Carolina is also setting up retail stores where people can sit down and learn more about health reform. The insurance company is also attending events in communities across the state to get the word out.

“Because the ACA is complicated and changes will affect everyone differently, we are offering the tools and resources to help North Carolinians understand their unique situation and options. We are making information and tools available online at nchealthreform.org, in retail stores and in person through community events,” Ryan Vulcan, a spokeswoman for the insurance company, said in an email.

The company plans to open a retail store at 1854 Hendersonville Road in Asheville in early October.

In addition to education efforts, the nonprofit group, Protect Your Care North Carolina, has been holding events to “to counter the negative spin that’s out there” about the health care law, said Candice Davies, with the organization.

The group’s goal is making sure the Affordable Care Act is fully implemented, she said.

The organization held a recent event in Asheville that featured several speakers talking about the effects of having no insurance or high cost insurance.